Chronic Obstruction of the Duodenum by the Root of the Mesentery

E. A. CODMAN
1908 Boston Medical and Surgical Journal  
have some causative relation to duodenal ulcer and the so-called " hunger pain," supposed to be due to hyperchlorhydria. I further ventured to prophesy that in the next few years we should hear more about duodenal stasis. Curiously enough, recent issues of the Journal of Medical Research, the Annals of Surgery and the Boston Medical and Surgical Journal show that attention is now tending toward this problem. The authors who have written these articles seem to have allowed the acute condition of
more » ... acute condition of complete obstruction to occupy their whole attention and have not yet concerned themselves with the incomplete or chronic form. This is but natural, and is parallel with the history of the surgical investigation of other organs. Appendicitis, gallstone disease, etc., have gone through the same story. Obstruction of the duodenum by the root of the mesentery has forced itself on our attention by the alarming acute condition; now let us turn to investigating its milder and more subtle ways of producing trouble. There must be a wide range between complete obstruction and physiological obstruction. I also raised the question whether we were right in attributing " hunger pain " in every case to acidity. May the alkaline disturbances of the duodenum not give disagreeable sensations? I know that I have myself been annoyed by quite severe epigastric pain and yet felt that my stomach was quite comfortable and my food being well digested. The duodenum is a more complicated organ than the stomach and therefore more likely to get out of order. My contentions are these: 1. That in the human being the transverse portion of the duodenum is more or less compressed by the root of the mesentery. 2. That slight anatomical deviations from the normal or certain pathological conditions may increase this pressure to a varying extent up to the point of complete occlusion of the gut. 3. That when this pressure reaches a degree great enough to give more resistance to the muscular efforts of the duodenum than the closed pylorus, the condition becomes of pathological significance. 4. That thus anatomically the duodenal secretions are brought in contact with mucous membranes unfitted physiologically to withstand their corrosive action. 5. That the obstruction favors stasis in the duodenum and thus bacterial invasion of the tissues. 6. That if the above propositions can be proved they will materially alter the present conceptions of the etiology and treatment of a variety of pathological conditions, e. g., hyperchlorhydria, nervous dyspepsia, duodenal and gastric ulcer, pancreatitis, cholelithiasis, persistent vomiting after laparotomy and in pregnancy, and excessive fluid drainage from wounds in the common duct and duodenum. I believe that it can be shown that certain facts collected about the duodenum by Dwight in Anatomy, Cannon in Physiology, Tiirck in Experimental Bacteriology, and Ochsner and others in Operative Surgery tend to substantiate my contentions. I will take these six propositions up in order. A considerable variation is found in the way the folds of mesentery carrying these two vessels cross the transverse duodenum; but whenever the latter extends to the aorta or to the left beyond it, the superior mesenteric artery will inevitably press it against the aorta and vertebral column. Just how often this occurs is a matter for a large series of statistics, but a fair idea can probably be obtained from what Dwight says: " In the 54 cases already mentioned, the duodenum was on the right of the aorta till just before the terminal flexure 26 times. It was wholly on the right 6 times. The fourth part lay in front of the aorta 11 times and the third part actually crossed the aorta 11 times." Thus in every individual the transverse portion of the duodenum is crossed by the root of the mesentery, and the contents of the gut must pass underneath a bridge between the vertebral column and the superior mesenteric artery. In the erect position the lumen of the gut must be a vertical slit compressed in proportion to the weight of more or less of the intestine. This compression occurs in all adult human beings, but will be greatest in those in whom the transverse portion of the duodenum crosses the aorta or possibly in those in whom the other extreme exists. In thinking over some method of demonstrating that in certain cases' such an obstruction to the duodenum did exist, I recollected that in his anatomical lectures Professor Dwight used to show us certain wax casts of the duodenum. On inquiring, I found that some years ago he had made a large number of these casts and had written a paper on the normal anatomy of this organ. This paper, from which the above quota-
doi:10.1056/nejm190804161581601 fatcat:ab4gyokmmvfrvbaecxruu53mfy